Evaluation of a computer-based and counseling support intervention to improve HIV patients' viral loads.

We sought to integrate a brief computer and counseling support intervention into the routine practices of HIV clinics and evaluate effects on patients' viral loads. The project targeted HIV patients in care whose viral loads exceeded 1000 copies/ml at the time of recruitment. Three HIV clinics initiated the intervention immediately, and three other HIV clinics delayed onset for 16 months and served as concurrent controls for evaluating outcomes. The intervention components included a brief computer-based intervention (CBI) focused on antiretroviral therapy adherence; health coaching from project counselors for participants whose viral loads did not improve after doing the CBI; and behavioral screening and palm cards with empowering messages available to all patients at intervention clinics regardless of viral load level. The analytic cohort included 982 patients at intervention clinics and 946 patients at control clinics. Viral loads were assessed at 270 days before recruitment, at time of recruitment, and +270 days later. Results indicated that both the control and intervention groups had significant reductions in viral load, ending with approximately the same viral level at +270 days. There was no evidence that the CBI or the targeted health coaching was responsible for the viral reduction in the intervention group. Results may stem partially from statistical regression to the mean in both groups. Also, clinical providers at control and intervention clinics may have taken action (e.g., conversations with patients, referrals to case managers, adherence counselors, mental health, substance use specialists) to help their patients reduce their viral loads. In conclusion, neither a brief computer-based nor targeted health coaching intervention reduced patients' viral loads beyond levels achieved with standard of care services available to patients at well-resourced HIV clinics.

Prospective State and Trait Predictors of Daily Medication Adherence Behavior in HIV.

BACKGROUND: Many persons living with HIV (PLWH) are nonadherent to medication. Trait level measures that ask about predictors of adherence in the abstract may not adequately capture state level daily variability that more directly impacts adherence. OBJECTIVES: This preliminary study was designed to test six predictors of electronically monitored adherence at both the state and trait levels and to compare their relative effects. METHODS: Using a smartphone, 87 PLWH completed randomly cued daily surveys on thoughts, mood, stress, coping, social support, and treatment motivation. All participants also completed baseline surveys on each construct. These state and trait variables were tested as prospective predictors of next-day adherence in multilevel models, and their relative importance was quantified. The analysis sample consisted of 53 PLWH who stored their most frequent antiretroviral medication in a bottle that time-stamped openings to measure adherence. RESULTS: Higher state level motivation, OR = 1.55, 95% CI [1.07, 2.24], and negative mood, OR = 1.33, 95% CI [1.07, 1.63], predicted greater adherence the following day. Importantly, these effects were only found at the state level. Trait level control beliefs predicted greater adherence, OR = 1.65, 95% CI [1.17, 2.35], but contrary to prediction, validated trait level measures of mood, stress, coping, social support, and motivation did not. DISCUSSION: Trait and state level measures predicted adherence, but there were differences between them. Motivation for treatment and negative mood predicted adherence when measured the preceding day, but not as aggregate measures. At the trait level, only control beliefs predicted adherence. Researchers should consider state level variations in mood and motivation as possible explanations for nonadherence. Interventions could be developed to target state level variables.

Enhanced personal contact with HIV patients improves retention in primary care: a randomized trial in 6 US HIV clinics.

BACKGROUND: The aim of the study was to determine whether enhanced personal contact with human immunodeficiency virus (HIV)-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact. METHODS: The study, conducted at 6 HIV clinics in the United States, included 1838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to 1 of 3 arms and continued to provide SOC practices to all enrollees: enhanced contact with interventionist (EC) (brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC + skills (organization, problem solving, and communication skills); or SOC only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least 1 primary care visit in 3 consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence). RESULTS: Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC + skills arms (visit constancy: risk ratio [RR], 1.22 [95% confidence interval {CI}, 1.09-1.36] and 1.22 [95% CI, 1.09-1.36], respectively; visit adherence: RR, 1.08 [95% CI, 1.05-1.11] and 1.06 [95% CI, 1.02-1.09], respectively; all Ps < .01). Intervention effects were observed in numerous patient subgroups, although they were lower in patients reporting unmet needs or illicit drug use. CONCLUSIONS: Enhanced contact with patients improved retention in HIV primary care compared with existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs. CLINICAL TRIALS REGISTRATION: CDCHRSA9272007.

A low-effort, clinic-wide intervention improves attendance for HIV primary care.

BACKGROUND: Retention in care for human immunodeficiency virus (HIV)-infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project. METHODS: Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10,018 patients in 2008-2009 (preintervention period) and 11,039 patients in 2009-2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods. RESULTS: Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients. CONCLUSION: Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.

Supporting the integration of HIV testing into primary care settings.

OBJECTIVES: We examined the efforts of the US network of AIDS Education and Training Centers (AETCs) to increase HIV testing capacity across a variety of clinical settings. METHODS: We used quantitative process data from 8 regional AETCs for July 1, 2008, to June 30, 2009, and qualitative program descriptions to demonstrate how AETC education helped providers integrate HIV testing into routine clinical care with the goals of early diagnosis and treatment. RESULTS: Compared with other AETC training, HIV testing training was longer and used a broader variety of strategies to educate more providers per training. During education, providers were able to understand their primary care responsibility to address public health concerns through HIV testing. CONCLUSIONS: AETC efforts illustrate how integration of the principles of primary care and public health can be promoted through professional training.

Recommendations and reality: perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions.

In 2006, the Centers for Diseases Control and Prevention (CDC) released recommendations calling for routine HIV testing to be offered to those ages 13 to 64 as a standard of general health care. This recommendation included a plan to conduct HIV testing as part of a general consent. The reasoning and evidence for this recommendation is supported by experts, patients, and sponsored screenings by the CDC. The rationale behind this approach includes that knowledge of one's HIV status helps (1) infected individuals adopt risk-reduction behaviors and access to life-prolonging treatment and (2) uninfected individuals maintain behaviors that reduce their risk of becoming infected. This article discusses the perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions that can be part of a nurse-led contribution to develop and adopt innovative, patient-centered care models that can address the need for screening.

Comparison of HIV Screening Strategies in the Emergency Department: A Randomized Clinical Trial.

Importance: The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown. Objective: To compare strategies for HIV screening when integrated into usual ED practice. Design, Setting, and Participants: This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021. Interventions: Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays. Main Outcomes and Measures: New HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs). Results: A total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47). Conclusions and Relevance: Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses. Trial Registration: ClinicalTrials.gov Identifier: NCT01781949.

Feasibility of a daily electronic survey to study prevention behavior with HIV-infected individuals.

The daily experiences of persons living with HIV (PLWH) are important but under-studied as predictors of HIV prevention behavior. Ecological momentary assessment (EMA) is an intensive within-subjects data collection method that can be used to examine daily experiences. To determine whether PLWH would participate in EMA, we conducted a feasibility study with 21 PLWH. The method was acceptable to men and women from diverse backgrounds, with 81% (17/21) completing 2 months of daily surveys, and 67% (14/21) completing 6 months. Measures were completed on 72% of study days. Only 6% of records had missing data. Daily survey completion decreased over time. Participants reported that EMA was easy and did not influence their behaviors. Results suggest EMA is feasible with PLWH.

Outcomes of multimodal training for healthcare professionals at an AIDS education and training center.

There is an ongoing need for continuing professional education (CPE) in the rapidly changing field of HIV care, but the best instructional methods remain a subject of debate. This study assessed the effects of training at an AIDS Education and Training Center (AETC) over an 18-month period. Health care professionals (HCP) who attended more than one training event showed small but significant improvements over time in HIV-related clinical practice behaviors. The type of training also predicted self-reported practice behavior, with interactive trainings and individual consultations associated with greater change, and intensive clinical training activities associated with a faster rate of change but not better scores on the self-reported behavior measure. Participants also reported high levels of satisfaction, knowledge improvement, and intention to change after each training event; however, these results were unrelated to whether trainees actually reported improved practice behavior.

Motivation as a Mechanism for Daily Experiences' Effects on HIV Medication Adherence.

Medication adherence is a challenge for people living with HIV (PLWH), who may experience a gap between their intentions and everyday behaviors. We measured PLWH's (n = 87) daily experiences and tested a model to explain the intention-behavior gap. Participants completed baseline questionnaires, then used a smartphone-based survey and an electronic pill bottle to provide daily data for the next 10 weeks. These PLWH, with generally well-controlled HIV, were nevertheless adherent on only 73% of study days. Multilevel analyses were used to test predicted relationships between variables (n = 58). Four of five theory-based daily measures predicted motivation for antiretroviral therapy (betas = 0.06-0.10), and motivation, in turn, predicted adherence. Consistent with our theory, control beliefs, mood, and social support had indirect effects on adherence. However, stress and coping did not. Daily experiences affect adherence, even in PLWH with well-controlled HIV. Providers should ask about everyday changes in motivation.

Prevention with HIV-infected men: recommendations for practice and research.

In the United States in 2004, 74% of the new AIDS cases and 70% of the new HIV cases were in men; in addition, 75% of the cases of HIV in women were classified as heterosexually acquired. These numbers make it clear that expanded prevention efforts for men who are infected with HIV would make a large contribution to containing the epidemic. This report explores epidemiologic and psychosocial issues related to prevention in men with HIV and compares how those variables relate to prevention efforts. The report ends with a discussion of a method to approach HIV risk reduction in clinical care settings.

Changes in clinician ability to assess risk and help patients determine the need for hiv testing: a comparison of three teaching methods.

An estimated one of four people with HIV in the United States do not know they have the infection. The Centers for Disease Control and Prevention encourages HIV testing in clinical settings, but there is evidence that this is not done on a regular basis. The purposes of this study were to (a) compare two less traditional teaching methods with a classroom method to determine whether the less traditional methods resulted in greater improvement of clinician knowledge, skill, and willingness to perform HIV risk assessment as the basis for recommending HIV testing; and (b) find out whether there were significant differences in convenience, cost, learner preference, or learner acceptance that would make one method more desirable than the others. Findings from participants in the standardized patient interaction with facilitator feedback (FB) and the case-based self-study module (SSM) were not different from those of participants in the interactive classroom education method (CL). Generally, there were positive changes in knowledge, attitudes, and behaviors over time. Participants preferred standardized patient interaction (FB) and interactive classes (CL) to self-study modules (SSM).

Brief report on ecological momentary assessment: everyday states predict HIV prevention behaviors.

BACKGROUND: Prevention behaviors help persons living with HIV (PLWH) to avoid transmitting HIV, and psychological variables have been found to predict HIV prevention behaviors. These variables have typically been measured using retrospective questionnaires about average psychological states over a period of time, which are likely to be biased by selective recall and interpretation. Measuring the same variables as momentary states, in the day-to-day context where they actually occur, may reveal different relationships to behavior. FINDINGS: 21 PLWH completed daily surveys about momentary states and prevention behaviors. Brief, validated measures were used to assess control beliefs, mood, stress, coping, social support, stigma, knowledge, and motivation. We used multilevel models to predict prevention behaviors from momentary states the previous day, while controlling for the effect of multiple observations from the same person over time. Participants reported a moderate overall level of HIV prevention behaviors during the 6-month study. Although lapses in prevention were infrequent, there was room for improvement. Control beliefs, mood, and motivation had significant prospective effects on HIV prevention behaviors, rs = 0.07-0.21. Stress and coping had effects approaching significance. CONCLUSIONS: Some momentary states predicted prevention behaviors, providing partial support for the motivational model. This finding supports past research showing effects of momentary states on behavior, and advances the science by testing multiple predictors. High within-sample diversity strengthened generalizability, but the overall sample size was small and the findings require replication. Future research should continue to examine the everyday experiences of PLWH as influences on their behavior.

Enfuvirtide nursing guidelines: a report from the Association of Nurses in AIDS Care Expert Panel on Enfuvirtide.

Enfuvirtide is the first of a new class of antiretrovirals know as fusion inhibitors approved for the treatment of HIV infection. It is administered via a subcutaneous injection. The patient is responsible for reconstitution from a powder and self-injection. Nurses caring for patients using enfuvirtide need a solid knowledge base about enfuvirtide administration and side effects in order to effectively educate and manage patients taking enfuvirtide. Enfuvirtide's safety and efficacy reported from phase III trials are summarized. Nursing guidelines were developed by the Association of Nurses in AIDS Care Expert Panel on Enfuvirtide. The guidelines, including suggestions on assessment, education, and management of side effects are reviewed. Teaching tools and resources are offered to assist in patient management. In addition, suggestions for proper syringe disposal and traveling with enfuvirtide are offered.

Brief report: Validation of a quantitative HIV risk prediction tool using a national HIV testing cohort.

Routine screening is recommended for HIV detection. HIV risk estimation remains important. Our goal was to validate the Denver HIV Risk Score using a national cohort from the Centers for Disease Control and Prevention. Patients of 13 years and older were included, 4,830,941 HIV tests were performed, and 0.6% newly diagnosed infections were identified. Of all visits, 9% were very low risk (HIV prevalence = 0.20%), 27% low risk (HIV prevalence = 0.17%), 41% moderate risk (HIV prevalence = 0.39%), 17% high risk (HIV prevalence = 1.19%), and 6% very high risk (HIV prevalence = 3.57%). The Denver HIV Risk Score accurately categorized patients into different HIV risk groups.

Hard-to-reach providers: targeted HIV education by the national AIDS education and training centers.

A national system of AIDS Education and Training Centers (AETCs) has received federal funding since 1987 to provide education to health care personnel (HCP) about HIV infection. The purpose of this study is to describe how AETC program personnel define and recognize HCP who are hard to reach and educate about HIV and to clarify the issues that make providers hard to reach. Twenty-three semistructured telephone interviews were used to collect data from AETC faculty and staff. Respondents were asked to identify the types of HCP who are hard to reach and to discuss why they are hard to reach. Themes identified to establish which HCP are hard to reach include specific professional groups (especially physicians and dentists) as well as providers who treated less than 10 HIV-infected clients and some HIV-expert clinicians. Themes identified to establish why they are hard to reach include convenience, isolation, and attitudes. Analysis posits that hard-to-reach HCP fall into identifiable categories: "already know the information," "don't know they don't know the information," "don't think they need to know the information," or "don't want to know the information." Respondents also identified innovative ways to approach hard-to-reach providers.